Rosen & Barkin's 5-Minute Emergency Medicine Consult (119 page)

FOLLOW-UP

• Injuries requiring admission
  
  • Partial-thickness burns of noncritical areas (excludes eyes, ears, face, hands, feet, or perineum) involving 10–20% of BSA in adults (>10 yr and <50 yr)
    
  • Partial-thickness burns of noncritical areas involving 5–10% of BSA in children <10 yr
    
  • Suspicion of nonaccidental trauma
    
  • Patients unable to care for wounds in outpatient setting (e.g., homeless patients)
    
• Injuries requiring transfer/admission to a burn center
  
  • Partial-thickness or full-thickness burns involving ≥10% of BSA
    
  • Full-thickness burns involving >5% of BSA
    
  • Partial-thickness and full-thickness of face, hands, feet, genitalia, perineum, or major joints
    
  • Electrical burns, including lightning injury
    
  • Significant chemical burns
    
  • Inhalation injury
    
  • Patients with pre-existing illness that could complicate management
    
  • Patients with concomitant trauma or social barriers
    

Partial-thickness burns of <10% of BSA in adults (<5% in children or the elderly) involving noncritical areas only. Patients must be reliable, able to manage wounds as outpatients and obtain follow-up.

Maintain low threshold for referral to burn specialist whenever there is raised concern regarding cosmesis, involvement of hands/face/eyes/perineum, or if burn is overlying a joint.

1–2 days after the injury to assess for early infection, saturation of dressings, pain control

• Early IV fluid rehydration is essential
  
• Intubate early for signs of respiratory distress; must recognize potential for airway involvement
  
• Early pain control in all burns
  
• Monitor for hypoglycemia in children
  

• Committee on Trauma, American College of Surgeons. Guidelines for the operation of burn units.
  Resources for Optimal Care of the Injured Patient
  ; 2006:79–86.
  
• Pham TN, Cancio LC, Gibran NS. American Burn Association practice guidelines burn shock resuscitation.
  J Burn Care Res
  . 2008;29(1):257–266.
  
• Toon MH, Maybauer MO, Greenwood JE, et al. Management of acute smoke inhalation injury.
  Crit Care Resusc.
  2010;12:53–61.
  
• Cancio LC, Lundy JB, Sheridan RL. Evolving changes in the management of burns and environmental injuries.
  Surg Clin North Am
  . 2012;92(4):959–986.
  

CODES

• 949.0 Burn of unspecified site, unspecified degree
  
• 949.1 Erythema [first degree], unspecified site
  
• 949.2 Blisters, epidermal loss [second degree], unspecified site
  

BASICS

• Bursae are synovial fluid-filled sacs:
  
  • ∼150 are located between bones, ligaments, tendons, muscles, and skin.
    
• They provide lubrication to reduce friction during movement.
  
• Bursitis is inflammation of a bursa caused by trauma and overuse, infection, crystal deposition, or systemic disease.
  
• Chronic bursitis can lead to proliferative changes in the bursa.
  
• Commonly affected sites:
  
  • Shoulder (subacromial)
    
  • Elbow (olecranon): Usually secondary to trauma
    
  • Hip (greater trochanter, ischial, iliopsoas): More common in elderly
    
  • Knee (prepatellar and pes anserine): Secondary to trauma or arthritis
    
  • Foot (calcaneal): Almost always secondary to improperly fitting shoes/heels
    

• Trauma (most common cause):
  
  • Specific traumatic event or repetitive use of associated joints
    
• Infection: Secondary to direct penetration; may be obvious or microscopic:
  
  • Higher risk with diabetes, chronic alcohol abuse, uremia, gout, immunosuppression
    
  • 90% caused by
    Staphylococcus
    spp.
    
• Crystal deposition: Calcium phosphate, urate
  
• Systemic disease: Rheumatoid arthritis, gout, ankylosing spondylitis, psoriatic arthritis, lupus, rheumatic fever
  

DIAGNOSIS

• Acute or chronic
  
• History of trauma, overuse, or prolonged pressure
  
• Pain with increased activity at respective joint or with pressure
  
• Functional complaints (e.g., limping)
  
• History of localized swelling
  
• Screen for symptoms of systemic disease
  
• History of gout or pseudogout or rheumatologic disease
  
• History of recent procedure at bursa (e.g., aspiration, injection, etc.)
  

• Tenderness to palpation is minimal to mild in aseptic bursitis.
  
• Localized pain with movement
  
• Often reduced active range of motion (ROM) with preserved passive ROM
  
• Localized swelling, particularly with superficial bursae
  
• Skin trauma overlying bursa
  
• Warmth and erythema*
  
• May be febrile in septic bursitis
  

*NB: The constellation of erythema, warmth, swelling, and exquisite tenderness are common in septic bursitis.

• Full assessment of adjacent musculoskeletal structures
  
• Any suspicion of infection warrants aspiration of bursae (especially olecranon and prepatellar bursae).
  
• Lateral approach to prevent a needle tract directly over lines of tension of the joint
  
• Aspiration of hip and other deep bursae may be guided in ED by US or deferred to consultants.
  

• Serum labs:
  
  • Suspected infection: CBC with differential
    
  • Evaluation of related systemic disease (e.g., uric acid level for gout); ESR and CRP in rheumatologic disease
    
  • Send serum glucose if bursal fluid aspiration is done
    
• Bursal fluid analysis:
  
  • Send fluid for complete cell count with differential, glucose, total protein, crystal determination, Gram stain, and culture.
    
  • Cultures must always be sent.
    
  • Normal fluid: Fluid is clear yellow with 0–200 WBCs, 0 RBCs, low protein, and glucose is same as serum.
    
  • Traumatic bursitis: Fluid is bloody/xanthochromic with <1,200 WBCs, many RBCs, low protein, and normal glucose.
    
  • Septic bursitis: Fluid is cloudy yellow with >50,000 WBCs, few RBCs, slightly increased protein, and decreased glucose; bacteria on Gram stain.
    
  • Rheumatoid and microcrystalline inflammation (aseptic bursitis): Fluid is yellow, sometimes turbid, and has 1,000–40,000 WBCs, few RBCs, slightly increased protein, and variable glucose; microscopic exam for crystals.
    

• Radiographs may demonstrate soft tissue swelling or adjacent chronic arthritic changes or calcium deposits:
  
  • Especially recommended when trauma is involved to rule out fracture or foreign body
    
• MRI and US may aid in diagnosis of deep bursitis and in defining the extent of septic bursitis.
  
• CT scans can also help differentiate septic from nonseptic bursitis.
  

• Arthritides: Septic, inflammatory, rheumatoid and degenerative joint (osteoarthritis)
  
• Gout and pseudogout
  
• Tendonitis, fasciitis, epicondylitis
  
• Fracture, tendon/ligament tear, contusion, sprain
  
• Osteomyelitis
  
• Nerve entrapment
  
• Also in hips: Neuritis, lumbar spine disease, sacroiliitis
  

TREATMENT

May be difficult to distinguish from fractures; suspicious joints should be immobilized, particularly in the setting of trauma.

• Immobilize joint if pain is severe.
  
• Shoulders should not be immobilized for >2–3 days because of the risk of adhesive capsulitis.